Study: Observation is a good strategy when caring for children who present with minor blunt head trauma
Take some time to monitor symptoms before ordering CT scans
A new study bolsters earlier findings that children who present to the ED with minor blunt head trauma can benefit from a period of observation before physicians decide whether to order computed tomography (CT) scans. Researchers note that the strategy significantly reduces the number of CTs that are required in these cases, reducing the risks associated with exposure to ionizing radiation.
• In a single-center study, researchers compared children who were observed with children who were not observed prior to CT decisions being made. They found that every hour of observation time was associated with a decrease in the CT rate.
• Just 5% of the patients who were observed proceeded to undergo CT scans; 34% of the patients who were not observed underwent immediate CT scans.
• Researchers note that troubling symptoms such as headache, vomiting, or altered mental status often resolve with time, negating the need for a CT scan.
• While more than 500,000 children present to EDs in the United States each year with blunt head trauma injuries, very few are found to have significant traumatic brain injuries.
A new study strongly suggests that for children who present to the ED with minor blunt head traumas, a short period of observation can make an important difference in helping clinicians determine whether to order computed tomography (CT) scans or not.1 In fact, researchers note that the longer a child with minor blunt head trauma remains on observation, the less likely that child is to require a CT scan.
"Observation is a great strategy because you can keep the child in the ED and, oftentimes, children who right after an injury are shaken up, have some symptoms that start to clear up after the initial episode," explains Lise Nigrovic, MD, MPH, a co-author of the study and a pediatric emergency physician at Boston Children's Hospital in Boston, MA. "If the symptoms worsen, you can always go and get a CT scan, but, in many cases, they get better."
This is important, says Nigrovic, because a period of observation can enable children to avoid the harmful effects of ionizing radiation that go along with CTs. "This is not about cost. There is a radiation risk to a child's growing brain," she explains. "Usually parents are pretty on board with [a decision to opt for observation] and are very willing to wait so they can avoid a test that has a potential risk."
Further, the study authors stress that while more than 500,000 children per year present to EDs with blunt head trauma injuries, very few of these patients are found to have significant traumatic brain injuries.
Consider the evidence
In the single-center study, researchers performed a prospective observational cohort study of all the children who presented with minor blunt head trauma over a 20-month period, between April of 2011 and December of 2012. Emergency physicians observed about half of the 1,381 study participants before deciding whether to order CTs, and in most of these cases symptoms — ranging from abnormal mental status to vomiting and headache — improved during the observation period.
The researchers note that every hour of observation time was associated with a decrease in the CT rate for children in all three traumatic brain injury risk groups, as specified on the Pediatric Emergency Care Applied Research Network (PECARN) risk prediction tool for traumatic brain injury. Ultimately, just 5% of patients who were observed proceeded to undergo CT scans. Of the 705 patients who were not observed, 34% underwent immediate CT scans. A total of eight patients in the study had what the researchers describe as clinically important traumatic brain injuries. All of these children were classified as high risk, and none were observed before a CT decision was made.
While this study was relatively small, it follows a much larger study that found that the use of observation significantly reduces the use of CT scans in children who present with blunt head traumas. Nigrovic was the lead author on that study, which was published in 2011.2
Monitor symptoms, then decide
The strategy of using observation as a management strategy in these cases is particularly helpful to clinicians who are caring for patients who are neither low risk nor high risk, but rather somewhere in between, explains Nigrovic. "These are patients who may not be severely symptomatic when they come in, but they may have that one symptom that makes you think about them, and that is the perfect group for observation," she explains. "If you have to make a decision right away, you might think seriously about getting some neuro imaging, but if you have time, which I argue is a good strategy, oftentimes many of those children's symptoms will get better. And if they don't, you have the patients in a safe place where you can go to the next step."
Nigrovic adds that most CTs that are conducted on these types of patients are negative. "We are doing too many tests for the amount of injuries that these children actually have. This is one strategy to selectively CT those who have symptoms that worsen over time," she says.
While fear of litigation may play a role in driving up the use of CT in these cases, Nigrovic suggests that a bigger factor may be that physicians tend to overestimate the risk of a bad outcome. "Those bad cases stand out in your mind. They end up in case reports, so you overestimate," she says. "Medical decision-making is always complex."
While the researchers did not determine how long a patient should remain in observation, Nigrovic suggests that the period of importance in these cases is generally four to six hours following the injury. "If a child comes in two hours after an injury and you decide you want to observe this patient, you may be watching him for two hours," she explains. "It is not long-term observation. There is no additional laboratory testing or things like that. They just need to be monitored and can be reassessed if things worsen."
References
1. Schonfeld D, Fitz B, Nigrovic L. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Ann Emerg Med. 2013. [Epub ahead of print]
2. Nigrovic L, Schunk J, Foerster A, et al. The effect of observation on cranial computer tomography utilization for children after blunt head trauma. Pediatrics 2011;127: 1067-1073.
• Lise Nigrovic, MD, MPH, Pediatric Emergency Physician, Boston Children's Hospital, Boston, MA. E-mail: [email protected].
